Let’s Operate on Interoperability

Wednesday, MedCity News and Life as a Healthcare CIO ran what I believe to be a very important piece on interoperability by Dr. John D. Halamka. I don’t agree with him that attempts to legislate interoperability into being should be jettisoned completely, but most of his points ring true.

Early on he asks the question that SHOULD be core to the HIT and Telemedicine industries, but especially for EHR vendors: “So what is our next step to help providers…to the point that Congress no longer wants to legislate the solution to the problem?”

What a question! EHR developers/vendors may not be thinking from that perspective…or maybe they have and just don’t care. Certainly, providing data across to your competitors’ products without charging money isn’t very motivating. Imagine if EHRs believed the point of their software was to move that information back and forth with other EHRs?

As a matter of fact, that could be the case: The Argonaut Project (which Dr. Halamka refers to multiple times) appears to prove that some EHRs are willing to give it a try…especially the big dogs like Epic and Cerner. But Argonaut could be a way of fending Congress off…a little too true to the words of Dr. Halamka’s question rather than its spirit. The dangers of this are inherent in another assertion he makes (emphasis mine): “The role for Congress should be to hold us accountable for the outcomes we want to achieve.”

You see, I’m afraid, to a certain extent, that that’s what’s happening. The outcomes some of those affected may want to achieve may essentially be, well, corporate interests. Shouldn’t it be the outcomes that patients/doctors want to achieve?

This isn’t to let the CMS/ONC off the hook by any stretch. As Dr. Halamka notes, Meaningful Use doesn’t address defining care coordination or care management. (We’ll take a long, hard look at Meaningful Use again soon.) However, I don’t believe it’s generally accepted that it’s in what the EHR vendors or some of their larger hospital customers perceive as their best interests to make true, instinctive, workflow-friendly, EHR interoperability a reality.

Or, it could simply be a technological difficulty.

Regardless, I can see how CMS feels the need to legislate this. Often in history we discover that change didn’t happen until law forced the issue (segregation, anyone? conservation?)…and then as an industry was created to make those changes happen better, private industrial innovation eventually introduces solutions that benefit the regulated businesses while surpassing the regulations.  Does this mean that legislation is usually pretty far off the mark? Unfortunately, yes. But if the industry is moving too slow on its own or may have a conflict of interest, well…as they’d say in medicine: Let’s stop the bleeding. Then we can conduct surgery.

Dr. Hamalka suggests that Meaningful Use be eliminated. I disagree and will write on that next week. Meaningful Use (and HRRP as well) has many issues, namely unrealistic goals due to a poor understanding of causality behind their data. (Don’t they have any economists–experts in cause and effect–helping set these goals?) But let’s not throw the baby out with the bathwater. I think adjustments will be made before the Stage 3 final ruling that will help cover some of the current concerns, and many hospitals have done fairly well if not better since entering the program.

But as for interoperability, I think I’m largely on the same page with Dr. Hamalka for what he believes the ONC should focus on, which I’ll provide in full here:

1. Facilitating the creation of a national provider directory for message routing;

2. Encouraging the adoption of a voluntary (I don’t think voluntary is necessary) national identifier for healthcare;

3. Providing guidance to streamline the heterogeneous patchwork of state privacy laws that are impeding information exchange; (I agree but think this may have to be federal.)

4. Serve as the coordinating body for aligning federal government health IT priorities;

5. Supporting private sector initiatives such as Argonaut that are simplifying the tools for health information exchange.

(except for my parentheticals, this section is directly from So what is interoperability anyway?)

He ends with a call to stop “saying we need interoperability,” but to, “include a crisp set of requirements for care management and care coordination with defined metrics of success.” I say, if those requirements are to be the replacement for interoperability, then, yes, let’s do that. Who would like to volunteer the first draft of those requirements and metrics? (I’m not qualified.)

Sadly, the truest way I see interoperability, by the definition we use with EHRs, will finally happen is that some very rich, politically-connected old white guy (or a close family member) will break a leg skiing in Aspen and suffer a severe complication resulting from no interoperability between his home hospital network in Connecticut and the hospital in Colorado.

When that happens, let’s just see how quickly interoperability takes place. But to speed the process up, let’s do get those requirements for care management and coordination as soon as possible.

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